1. Code patient: | 1. ________ |
2. Contacts: 1. Yes 2. No Cell/Telephone Number_________________ E-mail____________________ | 2. ________ |
3. Age (years): 1. <20 years 2. ≥20 years | 3. ________ |
4. Place of origin: 1. Capital City (Ceará/BRAZIL) 2. Countryside | 4. ________ |
5. Marital status: 1. Casada/união consensualMarried/Live with partner 2. SolteiraSingle | 5. ________ |
6. Occupation: 1. Works 2. Does not work | 6. ________ |
7. Education (Completed schooling years): 1. ≤9 years 2. >9 years | 7. ________ |